Neuro Adaptive Quiz 2 and 3

A nurse is caring for a client newly diagnosed with Guillain-Barré syndrome. The nurse expects which procedure will be considered as a treatment option? a. Hemodialysis b. Plasmapheresis c. Thrombolytic therapy d. Immunosuppression therapy

B

A nurse is teaching a client with multiple sclerosis (MS) about how to manage urinary retention. Which instructions should the nurse include in the teaching session? 1. Using Credé maneuver 2. Using an indwelling catheter 3. Using anticholinergic medications 4. Monitoring and restricting fluid intake to 800 mL daily 5. Monitoring for and reporting signs of urinary tract infection a. 1, 3, 5 b. 1, 4 c. 1, 5 d. 2, 3, 5

C

The nurse is caring for a client with a spinal cord injury. The client exhibits signs of autonomic hyperreflexia. What does the nurse recall is the most common cause of this response? a. Hemodynamic changes related to tilt table positioning b. Deteriorating myelin sheath c. Distended large intestine d. Crushed spinal cord

C

Discharge planning for an ambulatory client with Parkinson disease (PD) includes recommending equipment for home use that will help with activities of daily living. To foster independence, the nurse should promote the use of which equipment? a. A raised toilet seat b. Side rails for the bed c. A trapeze above the bed d. Crutches for ambulation

A

A client with myasthenia gravis asks the nurse why the disease has occurred. Which pathology underlies the nurse's reply? a. A genetic defect in the production of acetylcholine (ACh) b. An inefficient use of the neurotransmitter acetylcholine c. A decreased number of functioning acetylcholine receptor (AChR) sites d. An inhibition of the enzyme acetylcholinesterase (AChE), leaving the end plates folded

C

A nurse is caring for a group of clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS). Which information should the nurse consider when planning care for this group of clients? a. Progressive deterioration until death b. Deficiencies of essential neurotransmitters c. Increased risk for respiratory complications d. Involuntary twitching of small muscle groups

C

During a routine clinic visit of a client who has myasthenia gravis, the nurse reinforces previous teaching about the disease and self-care. The nurse evaluates that the teaching is effective when the client states which information? a. Plan activities for later in the day. b. Eat meals in a semirecumbent position. c. Avoid people with respiratory infections. d. Take muscle relaxants when under stress

C

A client with myasthenia gravis has increased difficulty swallowing. Which action will the nurse take to prevent the aspiration of food? a. Offer three large meals a day. b. Assess the client's respiratory status before and after meals. c. Seek a change in the diet prescription from soft foods to clear liquids. d. Schedule meals with the peak effect of an anticholinesterase muscle stimulant.

D

A client is admitted to the ambulatory health clinic with a diagnosis of Bell palsy. What is most appropriate for the nurse to do? a. Teach facial exercises. b. Prepare the client for surgery. c. Tape the client's affected eyelid open. d. Record symmetrical progression of the paralysis.

A

A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care? a. Aspiration b. Dehydration c. Nutritional imbalance d. Impaired communication

A

A client with multiple sclerosis is admitted to the hospital. The client's exacerbations have become more frequent and more severe. One day, the client's partner confides to the nurse, "Life is getting very hard and depressing, and I am upset with myself for thinking about a nursing home." After listening to the partner's concerns, which is the best response by the nurse? a. "You may be able to lessen your feelings of guilt by seeking counseling." b. "It would be helpful if you become involved in volunteer work at this time." c. "I recognize it's hard to deal with this, but try to remember that this too shall pass." d. "Joining a support group of people who are coping with this problem may be helpful."

D

A client is newly diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" Which is the nurse's best response? a. "Most individuals with your disease live a normal life span." b. "Is your family here? I would like to explain your disease to all of you." c. "The prognosis is variable; most individuals experience remissions and exacerbations." d. "Why don't you speak with your healthcare provider? You probably can get more details about your disease."

C

A nurse identifies that a client seems to be depressed after a thymectomy for treatment of myasthenia gravis. Which nursing action is most appropriate at this point? a. Recognize that depression often occurs after surgery b. Ask the primary healthcare provider to arrange for a psychologic consultation c. Reassure the client that things will feel better after the discharge date has been set d. Talk with the client about the prognosis and emphasize activities the client is still able to perform

D

An 80-year-old client with dementia of the Alzheimer type is admitted to a nursing home. A family member visits and remarks how thin and wrinkled the client has become. Which response by the nurse will help the family member most to understand the aging process? a. "Most people at that age should be careful about weight gain." b. "This is typical of older adults; they really don't eat well." c. "It looks as though the frequent tanning has taken its toll." d. "As we age, we lose the tissue that helps puff out the skin."

D

Which nursing action is specific to the plan of care for a client with trigeminal neuralgia? a. Be alert to prevent dehydration or starvation. b. Initiate exercises of the jaw and facial muscles. c. Apply ice compresses to the affected body area. d. Emphasize the importance of brushing the teeth.

A

A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment? a. The injury results in loss of the reflex arc. b. The injury is above the sixth thoracic vertebra. c. There has been a partial transection of the cord. d. There is a flaccid paralysis of the lower extremities.

B

During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, what does the nurse expect the client to manifest? a. Diminished visual acuity b. Increased muscular weakness c. Pronounced muscular atrophy d. Impairment in cognitive reasoning

B

The family member of a client with newly diagnosed Guillain-Barré syndrome comes out to the nurse's station and informs the nurse that the client is having difficulty breathing. What is the first action the nurse should do? a. Notify the healthcare provider. b. Go with the family member to assess the client. c. Send the nursing assistive personnel to take vital signs. d. Assure the family member this is a normal response for this disease.

B

A nurse is assessing a client with multiple sclerosis. Which common initial clinical effects should the nurse expect to find? Select all that apply. 1 . Headaches 2. Nystagmus 3. Skin infections 4. Scanning speech 5. Intention tremors a. 1, 3, 5 b. 2, 4 c. 2, 4, 5 d. 3, 5

C

After a client is treated for a spinal cord injury, the healthcare provider informs the family that the client is a paraplegic. The family asks the nurse what this means. Which explanation should the nurse provide? a. Lower extremities are paralyzed. b. Upper extremities are paralyzed. c. One side of the body is paralyzed. d. Both lower and upper extremities are paralyzed.

A

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply. i. Spasticity ii. Incontinence iii. Flaccid paralysis iv. Respiratory failure v. Lack of reflexes below the injury a. i, ii b. iii, iv c. iii, v d. iv, v

C

A client diagnosed with Bell palsy has many questions about the course of the disorder. Which information should the nurse share with the client? a. Cool compresses decrease facial involvement. b. Pain occurs with transient ischemic attacks (TIAs). c. Most clients recover from the effects in several weeks. d. Body changes should be expected with residual effects.

C

A client with multiple sclerosis is informed that it is a chronic progressive neurologic condition. The client asks the nurse, "Will I experience pain?" What is the nurse's best response? a. "Tell me about your fears regarding pain." b. "Analgesics will be prescribed to control the pain." c. "Pain is not a characteristic symptom of this condition." d. "Let's make a list of the things you need to ask your primary healthcare provider."

C

A client with myasthenia gravis asks the nurse, "What is going to happen to me and to my family?" Which information about what the client can anticipate should be incorporated into the nurse's response? a. High cure rate with proper treatment b. Slowly progressive course without remissions c. Chronic illness with exacerbations and remissions d. Poor prognosis, with death occurring in a few months

C

A nurse is caring for two clients. One has Parkinson disease, and the other has myasthenia gravis. For which common complication associated with both disorders should the nurse assess these clients? a. Cogwheel gait b. Impaired cognition c. Difficulty swallowing d. Nonintention tremors

C

A nurse is caring for a client with the diagnosis of Guillain-Barré syndrome with nasal cannula oxygen. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention? a. Auscultate for breath sounds. b. Suction the client's oropharynx. c. Administer and continue to monitor oxygen via nasal cannula. d. Place the client in the orthopneic position.

B

What nursing intervention is anticipated for a client with Guillain-Barré syndrome? a. Providing a straw to stimulate the facial muscles b. Maintaining ventilator settings to support respiration c. Encouraging aerobic exercises to avoid muscle atrophy d. Administering antibiotic medication to prevent pneumonia

B

A client with Guillain-Barré syndrome has been hospitalized for three days. Which assessment finding would the nurse expect and need to monitor frequently in this client? a. Localized seizures b. Skin desquamation c. Hyperactive reflexes d. Ascending weakness

D

A client with the diagnosis of multiple sclerosis experiences a sudden loss of vision and asks the nurse what caused it to happen. The nurse considers the common clinical findings associated with multiple sclerosis before responding. Which is the most probable cause of the client's sudden loss of vision? a. Virus-induced iritis b. Intracranial pressure c. Closed-angle glaucoma d. Optic nerve inflammation

D